Hospital Course
On presentation, the patient was found to have incompatible blood due to warm autoantibodies, precluding transfusion. On the second day of hospitalization, hemoglobin decreased to a nadir of 5.3 mg/dl. Rheumatological panel (Table 2) showed elevated IgM, positive rheumatoid factor, and anti-dsDNA. Positive direct antiglobulin test was positive for IgG and C3, and a presumptive diagnosis of acute warm hemolytic anemia complicating anemia of chronic disease was made. Following this diagnosis, the patient was given a single 125mg dose of methylprednisolone sodium succinate followed by high-dose oral prednisone (40mg/daily).
Nevertheless, the patient continued to deteriorate, developing worsening fatigue, pre-syncope and palpitations despite steroid administration and stabilized hemoglobin. At this time, the treating team was informed of the positive IGRA two years prior and lack of follow-up treatment for latent TB. Due to concern for TB re-activation, chest imaging was performed, along with repeat IGRA and infectious disease consult. While IGRA was negative, chest radiograph showed a small, laterally located lesion in the upper right lobe and focal consolidation of the upper left lobe (Figure 1). Isolation precautions were started, and empiric broad-spectrum antibacterial therapy was initiated for presumed pneumonia. CT imaging of the thorax showed necrotizing bronchopneumonia affecting the left upper lobe (Figure 2) with additional necrosis of the right middle lobe. Mild prominence of mediastinal lymph nodes was also appreciated. Additional tests for etiology included histoplasma antibodies, legionella urine antigen, as well as general mycology and bacteriology, however, antibody and culture tests were all initially negative. Furthermore, there was no evidence of neoplastic disease.
Because serologic testing was negative and sputum samples were unproductive despite sputum induction with hypertonic saline, a bronchioalveolar lavage (BAL) was performed. The sample demonstrated 4+ acid-fast organisms. Follow up PCR testing of BAL sample was positive for Mycobacterium tuberculosis and rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy was initiated. The patient was discharged shortly thereafter. Over the next 9 months, the patient had one episode of seronegative arthritis, and two additional episodes AIHA. TB was well controlled on RIPE therapy in these admissions, without evidence or reactivation.